Original Research
15 March 2011

What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study

Publication: Annals of Internal Medicine
Volume 154, Number 6

Abstract

Background:

Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation.

Objective:

To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates.

Design:

Qualitative study that used site visits and in-depth interviews.

Setting:

Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics.

Participants:

158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals.

Measurements:

Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method.

Results:

Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals.

Limitation:

The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed.

Conclusion:

High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI.

Primary Funding Source:

Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.

Get full access to this article

View all available purchase options and get full access to this article.

Supplemental Material

Supplement. Supplemental File: Methods

References

1.
Krumholz HMMerrill ARSchone EMSchreiner GCChen JBradley EHet al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009;2:407-13. [PMID: 20031870]
2.
Popescu IWerner RMVaughan-Sarrazin MSCram P. Characteristics and outcomes of America's lowest-performing hospitals: an analysis of acute myocardial infarction hospital care in the United States. Circ Cardiovasc Qual Outcomes. 2009;2:221-7. [PMID: 20031841]
3.
Krumholz HMWang YChen JDrye EESpertus JARoss JSet al. Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006. JAMA. 2009;302:767-73. [PMID: 19690309]
4.
Ross JSNormand SLWang YKo DTChen JDrye EEet al. Hospital volume and 30-day mortality for three common medical conditions. N Engl J Med. 2010;362:1110-8. [PMID: 20335587]
5.
Thiemann DRCoresh JOetgen WJPowe NR. The association between hospital volume and survival after acute myocardial infarction in elderly patients. N Engl J Med. 1999;340:1640-8. [PMID: 10341277]
6.
Baldwin LMMacLehose RFHart LGBeaver SKEvery NChan L. Quality of care for acute myocardial infarction in rural and urban US hospitals. J Rural Health. 2004;20:99-108. [PMID: 15085622]
7.
Allison JJKiefe CIWeissman NWPerson SDRousculp MCanto JGet al. Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI. JAMA. 2000;284:1256-62. [PMID: 10979112]
8.
Krumholz HMChen JRathore SSWang YRadford MJ. Regional variation in the treatment and outcomes of myocardial infarction: investigating New England's advantage. Am Heart J. 2003;146:242-9. [PMID: 12891191]
9.
Normand STGlickman MESharma RGMcNeil BJ. Using admission characteristics to predict short-term mortality from myocardial infarction in elderly patients. Results from the Cooperative Cardiovascular Project. JAMA. 1996;275:1322-8. [PMID: 8614117]
10.
Ross JSCha SSEpstein AJWang YBradley EHHerrin Jet al. Quality of care for acute myocardial infarction at urban safety-net hospitals. Health Aff (Millwood). 2007;26:238-48. [PMID: 17211034]
11.
Bradley EHHerrin JCurry LCherlin EJWang YWebster TRet al. Variation in hospital mortality rates for patients with acute myocardial infarction. Am J Cardiol. 2010;106:1108-12. [PMID: 20920648]
12.
Bradley EHCurry LARamanadhan SRowe LNembhard IMKrumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4:25. [PMID: 19426507]
13.
Marsh DRSchroeder DGDearden KASternin JSternin M. The power of positive deviance. BMJ. 2004;329:1177-9. [PMID: 15539680]
14.
Sternin JChoo R. The power of positive deviancy. An effort to reduce malnutrition in Vietnam offers an important lesson about managing change. Harv Bus Rev. 2000;78:14-5. [PMID: 10977192]
15.
Curry LANembhard IMBradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009;119:1442-52. [PMID: 19289649]
16.
Inui TS. The virtue of qualitative and quantitative research [Editorial]. Ann Intern Med. 1996;125:770-1. [PMID: 8929012]
17.
Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet. 2001;358:397-400. [PMID: 11502338]
18.
Patton M. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, CA: Sage; 2002.
19.
Sofaer S. Qualitative methods: what are they and why use them? Health Serv Res. 1999;34:1101-18. [PMID: 10591275]
20.
Spear SJBowen HK. Decoding the DNA of the Toyota production system. Harv Bus Rev. 1999;:96-106.
21.
van Dyck CFrese MBaer MSonnentag S. Organizational error management culture and its impact on performance: a two-study replication. J Appl Psychol. 2005;90:1228-40. [PMID: 16316276]
22.
Gordon GGDiTomaso N. Predicting corporate performance from organizational culture. J Manag Studies. 1992;29:783-798.
23.
Lincoln YSGuba EG. Naturalistic Inquiry. Newbury Park, CA: Sage; 1985.
24.
Morse JM. The significance of saturation. Qual Health Res. 1995;5:147-149.
25.
Glaser BStrauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine; 1967.
26.
Miles MBHuberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks, CA: Sage; 1994.
27.
Nielson Claritas. Population Facts 2009. Los Angeles: Nielson Claritas; 2009.
28.
Rathore SSMasoudi FAWang YCurtis JPFoody JMHavranek EPet al. Socioeconomic status, treatment, and outcomes among elderly patients hospitalized with heart failure: findings from the National Heart Failure Project. Am Heart J. 2006;152:371-8. [PMID: 16875925]
29.
Bradley EHHerrin JMattera JAHolmboe ESWang YFrederick Pet al. Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction. Med Care. 2005;43:282-92. [PMID: 15725985]
30.
Bradley EHNallamothu BKCurtis JPWebster TRMagid DJGranger CBet al. Summary of evidence regarding hospital strategies to reduce door-to-balloon times for patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Crit Pathw Cardiol. 2007;6:91-7. [PMID: 17804968]
31.
Krumholz HMBradley EHNallamothu BKTing HHBatchelor WBKline-Rogers Eet al. A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: An Alliance for Quality. JACC Cardiovasc Interv. 2008;1:97-104. [PMID: 19393152]
32.
Bradley EHNallamothu BKHerrin JTing HHStern AFNembhard IMet al. National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance. J Am Coll Cardiol. 2009;54:2423-9. [PMID: 20082933]
33.
Horwitz LIMoin TKrumholz HMWang LBradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755-60. [PMID: 18779462]
34.
Roy CLPoon EGKarson ASLadak-Merchant ZJohnson REMaviglia SMet al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143:121-8. [PMID: 16027454]
35.
Sutcliffe KMLewton ERosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-94. [PMID: 14744724]
36.
Patterson ESRoth EMWoods DDChow RGomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16:125-32. [PMID: 15051706]
37.
Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358:483-8. [PMID: 11513933]
38.
Mays NPope C. Rigour and qualitative research. BMJ. 1995;311:109-12. [PMID: 7613363]
39.
Sudman SBradburn NMSchwarz N. Thinking About Answers: The Application of Cognitive Processes to Survey Methodology. San Francisco: Jossey-Bass; 1996.

Comments

0 Comments
Sign In to Submit A Comment
Hugh, Mann, Physician 6 March 2012
Rx for Hospitals

The hospital is a battlefield in which doctors and nurses fight sickness. Doctors are officers, and nurses are enlisted. Doctors have authority, issue orders, enjoy comforts, and receive rewards; while nurses lack authority, take orders, do dirty work, and receive blame. This gross inequality is counterproductive, because it hurts nurses, creates internecine conflict, subverts the hospital's mission, and subjects patients to suboptimal healthcare. The Hippocratic Oath should include the doctor-nurse relationship.

Conflict of Interest:

None declared

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 154Number 615 March 2011
Pages: 384 - 390

History

Published online: 15 March 2011
Published in issue: 15 March 2011

Keywords

Authors

Affiliations

Leslie A. Curry, PhD
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Erica Spatz, MD
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Emily Cherlin, PhD, MSW
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Jennifer W. Thompson, MPP
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
David Berg, PhD
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Henry H. Ting, MD, MBA
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Carole Decker, RN, PhD
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Harlan M. Krumholz, MD, SM
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Elizabeth H. Bradley, PhD
From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.
Acknowledgment: The authors thank the members of the team who participated in the hospital site visits and data collection: Tashonna R. Webster, PhD, MPH, MS; Jersey Chen, MD; Kate Goodrich, MD, MHS; Robert L. McNamara MD, MHS; Jeptha P. Curtis, MD; Adam Landman, MD, MS, MIS; Katherine Hearn, RN, MPA; Sarah A. Roumanis, RN; Susannah Bernheim, MD, MHS; Chohreh Partovian, MD, PhD; and Marian Mocanu, MD.
Grant Support: By the Agency for Healthcare Research and Quality (R01-HS-016929), United Health Foundation, and the Commonwealth Fund (20090565).
Reproducible Research Statement: Study protocol, statistical code, and data set: Not available.
Corresponding Author: Leslie A. Curry, PhD, 60 College Street, Box 208034, New Haven, CT 06520-8034; email, [email protected].
Current Author Addresses: Drs. Curry and Bradley: 60 College Street, Box 208034, New Haven, CT 06520-8034.
Drs. Spatz and Krumholz: 1 Church Street, Suite 200, New Haven, CT, 06510.
Dr. Cherlin: 2 Church Street South, Suite 409, New Haven, CT 06520.
Ms. Thompson: 47 College Street, Suite 104, New Haven, CT 06510.
Dr. Berg: 146 McKinley Avenue, New Haven, CT 06515.
Dr. Ting: 200 First Street Southwest, Rochester, MN, 55905.
Dr. Decker: 4401 Womall Road, HI-5, Kansas City, MO, 64111.
Author Contributions: Conception and design: L.A. Curry, H.M. Krumholz, E.H. Bradley.
Analysis and interpretation of the data: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.
Drafting of the article: L.A. Curry, E. Cherlin, E.H. Bradley.
Critical revision of the article for important intellectual content: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.
Final approval of the article: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.
Administrative, technical, or logistic support: E. Cherlin, J.W. Thompson, E. Spatz.
Collection and assembly of data: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.

Metrics & Citations

Metrics

Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format





Download article citation data for:
Leslie A. Curry, Erica Spatz, Emily Cherlin, et al. What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study. Ann Intern Med.2011;154:384-390. [Epub 15 March 2011]. doi:10.7326/0003-4819-154-6-201103150-00003

View More

Login Options:
Purchase

You will be redirected to acponline.org to sign-in to Annals to complete your purchase.

Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.

Create your Free Account

You will be redirected to acponline.org to create an account that will provide access to Annals.

View options

PDF/EPUB

View PDF/EPUB

Related in ACP Journals

Full Text

View Full Text

Figures

Tables

Media

Share

Share

Copy the content Link

Share on social media